Human Bites Clinical Presentation

Updated: Mar 04, 2021
  • Author: Jeffrey Barrett, MD; Chief Editor: John L Brusch, MD, FACP  more...
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Presentation

History

A thorough, detailed history is necessary to facilitate communication between various health-care professionals involved in the treatment of the patient and to document why the plan of care was appropriate. (Photographic documentation should also be considered.) It is extremely important that the chart reflect the following:

  • An adequate initial evaluation

  • An appropriate care plan

  • That the patient was counseled regarding potential complications and importance of early and regular follow-up care

When questioned as to the nature of their injury, patients often mislead the examiner out of embarrassment or fear of legal repercussion. This is particularly common in bites that occur during sexual activity (eg, “love” bites to a breast). Consider all injuries dorsal to the MCP joint to be bite wounds until proven otherwise. Because explanations offered for such wounds often are misleading, extreme caution is necessary. While a careful explanation of the need for an accurate history may elicit the truth from the patient, experienced emergency physicians often treat such injuries as bites regardless of the history.

Most bite wound infections are not present at the initial emergency department (ED) visit. With closed-fist injuries, the initial injury often appears minor to the patient; thus, no care is sought until infection develops.

If a child receives a small laceration to the scalp or forehead during unwitnessed horseplay, carefully ascertain whether a tooth caused the wound, to minimize complications.

Other aspects of a patient's history that may influence care include the following:

  • Tetanus immunization status

  • Time delay from injury to presentation

  • Disability encountered

  • Presence of underlying immunosuppressive disease

Natural history of the wound

Obtain the following information about the natural history of the wound:

  • Circumstances surrounding the injury

  • Precipitating event or activity

  • Exact mechanism of injury

  • Time of occurrence

  • Location of occurrence

  • Whether the other party involved is known to the patient and available should testing be indicated

  • Treatment initiated prior to presentation

Signs and symptoms related to the wound

Obtain the following information about wound-associated signs and symptoms:

  • Pain

  • Fever

  • Swelling

  • Discharge or odor

  • Tobacco, alcohol, or recreational drug use

  • Medications or allergies to medications

  • Tetanus immune status

  • Ability to comprehend the magnitude of injury and to cooperate with the treatment plan

Comorbidities

Comorbid conditions that may place the patient at a higher risk for infection or its sequelae include the following:

  • Diabetes mellitus

  • Chronic edema of the region - Eg, prior ipsilateral axillary node dissection for an upper extremity wound

  • Prior splenectomy

  • Liver disease

  • Immunosuppression

  • Presence of a prosthetic valve or joint

  • Regional arterial or venous disease

Legal considerations

Human bite-injury cases are often assault cases and are more likely to involve the judicial system. With that in mind, documentation should be clear, concise, and complete. Moreover, most jurisdictions require medical professionals to report suspected child abuse. [11]

Next:

Physical Examination

A thorough physical examination is necessary to evaluate the overall state of health, comorbidities, nutritional status, and mental status of the patient.

Following the general physical examination, the clinician should turn his/her attention to the wound. Assessment of the wound can be quite difficult and is often inaccurately or inadequately performed.

Adequate examination of the wound may require administration of intravenous (IV) or oral pain medication to ensure patient comfort.

Examine hand injuries through the full range of hand motions, particularly in the case of clenched-fist injuries. Physicians must be wary of any laceration overlying the MCP joint. Additionally, carefully assess bite wounds of the fingers for deeper penetration into the tendon apparatus. Extending the wound may be necessary to fully evaluate underlying structures and the extent of the injury.

Wound characteristics

Important aspects of wound assessment include the following:

  • Location

  • Shape

  • Size

  • Type - Puncture, laceration, avulsion, or crush

  • Depth of penetration

  • Drainage - Quantity, character, odor

  • Presence of a foreign body - Tooth fragments, particulate matter

  • Loss of tissue

  • Tenderness

  • Asymmetry

  • Violation of tendon, cartilage, joint spaces, or bone - This may be difficult to detect on initial examination and may require operative exploration to adequately diagnose

  • Surrounding erythema, edema, cellulitis, or crepitus

  • Neurovascular status

  • Regional lymphadenopathy

The following points should be noted for specific bite wounds:

  • MCP wounds (closed-fist injury) - Integrity of the extensor tendons, signs of infection, crepitus, loss of knuckle height

  • Chomping injuries of the finger - Integrity of the extensor and flexor tendons, evidence of infection (including flexor tenosynovitis)

  • Ear bites - Loss of tissue, violation of cartilage

  • Other bites - Tissue loss, depth of penetration

All bite marks in a young child should raise suspicion of abuse. The normal intercanine distance of an adult is 2.5-4.0 cm. Therefore, any human bite marks with an intercanine distance over 3.0 cm were likely inflicted by an adult. [12]

Documentation guidelines

Although not standard in all centers, the following guidelines for wound documentation in cases of assault have been established by the American Board of Forensic Odontology [13] :

  • Photographic documentation

  • Wound diagram, including notation of arch pattern and intercanine width

  • Bite mark impressions

  • Swabbing of the wound for tissue typing

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